Use, Abuse, and Addiction

Opioid Intoxication

Intoxication for a person with opioid addiction after an intravenous self-injection or smoking has been described as consisting of four different states that can overlap over time: “rush,” “nod,” “high,” and “being straight” (Table 5.3). These states typically occur with 1–3 mg heroin or 3–15 mg morphine. Profound euphoria, termed the “rush,” occurs first, which has been described as occurring approximately 10 s after the beginning of the injection. The rush includes a wave of euphoric feelings, frequently characterized in sexual terms:

Table 5.3

States of Opiate Intoxication After Administering 1–3 mg Heroin or 3–15 mg Morphine

State

Duration

Effects

Rush

45 s

Intense pleasure, with waves of intense euphoria likened to sexual orgasm. In this first state, visceral sensations occur, with facial flushing and deepening of the voice. Although other effects show tolerance with chronic use, the rush is resistant to tolerance.

Nod

15–20 min

A state of escape from reality that can range from sleepiness to virtual unconsciousness. Addicts are described as calm, detached, and very uninterested in external events.

High

Several hours

This state follows the rush. It is a general feeling of well-being that can extend several hours beyond the rush and shows tolerance.

Being straight

Up to 8 h

This is the point at which the user is no longer experiencing the rush, nod, or high but also is not yet experiencing withdrawal. This state can last up to 8 h following an injection or smoking of heroin.

“So I snort again and holy f___ing s__t! I felt like I died and went to heaven. My whole body was like one giant f___ing incredible orgasm.”

(Inciardi JA. The War on Drugs: Heroin, Cocaine, Crime, and Public Policy. Mayfield, Palo Alto CA, 1986, p. 61.)

“After a while she asks me if I want to try the needle and I say no, but then I decide to go halfway and skin-pop [injecting into the muscle just beneath the skin]. Well, man, it was wonderful. Popping was just like snorting, only stronger, finer, better, and faster.”

(ibid, p. 62.)

“Travelin’ along the mainline was like a grand slam home run f___, like getting a blow job from Miss America. The rush hits you instantly, and all of a sudden you’re up there on Mount Olympus talking to Zeus.”

(ibid, p. 62.)

In this first state, visceral sensations are also experienced, including facial flushing and a deepening of the voice. Although other effects show tolerance with chronic use, the rush is resistant to tolerance. The second state is the “nod,” which is a state of escape from reality that can range from sleepiness to virtual unconsciousness and lasts 15–20 min. Individuals in this state are described as calm, detached, and noticeably uninterested in external events.

Following the nod, the third state occurs, called the “high.” The high is described as a general feeling of well-being and can last several hours beyond the rush. In contrast to the rush, however, the high shows tolerance. The fourth and final state is characterized as “being straight.” The user no longer experiences the rush, nod, or high but is also not yet experiencing withdrawal. This state can last up to 8 h following intravenous or smoked heroin.

The route of administration and infusion rate of that administration have profound effects on the subjective and physiological effects of opioids. In one study, healthy volunteers received intravenous injections of two doses of morphine at three different infusion rates. Faster infusions produced greater positive subjective effects than slower infusions on ratings of “good drug effect,” “drug liking,” and “high” (Figure 5.6). In experimental studies of heroin addiction, detoxified individuals with opioid addiction were allowed to intravenously self-administer heroin with self-regulated access to increasing doses over a 10 day period in a residential laboratory setting in a locked unit of a large psychiatric hospital. The early phase of heroin self-administration was accompanied by elated mood and decreased “somatic concern.” The later stages were characterized by a profound shift toward dysphoria, with notable increases in somatic concern, anxiety, depression, social isolation, and motor retardation. Initially, the reinforcing properties of heroin stemmed primarily from its ability to relieve tension and produce euphoria. However, as the frequency of drug self-administration increased, tolerance quickly developed to the euphorigenic effects, although single injections remained capable of producing brief periods of positive mood that lasted 30–60 min. This tolerance was accompanied by a distinct shift in the direction of psychopathology and dysphoria. Symptoms included sleep disturbances, social isolation, belligerence, irritability, less motivation for sexual activity, and motor retardation.

FIGURE 5.6 Mean peak change scores for the drug effect, drug liking, and high effects of morphine on a Visual Analog Scale (VAS) for different infusion rates and dosing conditions. Infusions were made over 2, 15, or 60 min in a blinded fashion. Subjects in all conditions received an hour-long infusion composed of drug and/or saline (depending on their infusion rate and dose condition). Three separate pumps were set to be activated by a nurse at time 0, 45, and 53 min for subjects in the 60, 15, and 2 min infusion rate conditions, respectively. Thus, subjects who received an hour-long infusion of drug received drug at all three time points. The subjects in the 15 min drug infusion condition received saline at time 0 min and drug at times 45 and 58 min. The subjects in the 2 min bolus drug infusion condition received saline at times 0 and 45 min and drug at time 58 min. VAS: On this measure, subjects rated the extent to which they experienced multiple effects (but only three are shown here: drug effect, drug liking, and drug-induced high). The analog scales consisted of a line approximately 100 mm in length, anchored at each end by “not at all” and “severe.” Subjects were instructed to move a cursor along the line reflecting the degree to which they were currently experiencing each of the six drug effects. Responses were recorded as a score ranging from 0 to 100. ARS: Self-reports of drug effects were rated on a modified version of an adjective rating scale listing 32 items describing typical opioid drug effects and withdrawal effects. Subjects were instructed to move a cursor along a line anchored at each end by “not at all” and “severe” for each symptom they had experienced. Responses were recorded as a score ranging from 0 to 9. Opioid drug effects included nodding, rush, loaded/high, coasting, itchy skin, etc., and withdrawal effects included such items as irritability, chills/gooseflesh, runny nose, yawning, etc. These data indicate a faster infusion rate is associated with more intense subjective effects of the drug. This supports the hypothesis that intravenous infusion of a drug may have more “addiction potential” than other routes of administration for which the infusion rate is slower. [Taken with permission from Marsch LA, Bickel WK, Badger GJ, Rathmell JP, Swedberg MD, Jonzon B, Norsten-Hoog C. Effects of infusion rate of intravenously administered morphine on physiological, psychomotor, and self-reported measures in humans. Journal of Pharmacology and Experimental Therapeutics, 2001, (299), 1056–1065.]

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